Kronman Andrea C, Ash Arlene S, Freund Karen M, Hanchate Amresh, Emanuel Ezekiel J
Section of General Internal Medicine, Evans Department of Medicine, Boston University Medical Center, Boston, MA 02118, USA.
J Gen Intern Med. 2008 Sep;23(9):1330-5. doi: 10.1007/s11606-008-0638-5. Epub 2008 May 28.
Medical care at the end of life is often expensive and ineffective.
To explore associations between primary care and hospital utilization at the end of life.
Retrospective analysis of Medicare data. We measured hospital utilization during the final 6 months of life and the number of primary care physician visits in the 12 preceding months. Multivariate cluster analysis adjusted for the effects of demographics, comorbidities, and geography in end-of-life healthcare utilization.
National random sample of 78,356 Medicare beneficiaries aged 66+ who died in 2001. Non-whites were over-sampled. All subjects with complete Medicare data for 18 months prior to death were retained, except for those in the End Stage Renal Disease program.
Hospital days, costs, in-hospital death, and presence of two types of preventable hospital admissions (Ambulatory Care Sensitive Conditions) during the final 6 months of life.
Sample characteristics: 38% had 0 primary care visits; 22%, 1-2; 19%, 3-5; 10%, 6-8; and 11%, 9+ visits. More primary care visits in the preceding year were associated with fewer hospital days at end of life (15.3 days for those with no primary care visits vs. 13.4 for those with > or = 9 visits, P < 0.001), lower costs ($24,400 vs. $23,400, P < 0.05), less in-hospital death (44% vs. 40%, P < 0.01), and fewer preventable hospitalizations for those with congestive heart failure (adjusted odds ratio, aOR = 0.82, P < 0.001) and chronic obstructive pulmonary disease (aOR = 0.81, P = 0.02).
Primary care visits in the preceding year are associated with less, and less costly, end-of-life hospital utilization. Increased primary care access for Medicare beneficiaries may decrease costs and improve quality at the end of life.
临终医疗护理往往昂贵且无效。
探讨临终时初级保健与医院利用之间的关联。
对医疗保险数据进行回顾性分析。我们测量了临终前6个月的医院利用情况以及前12个月内初级保健医生的就诊次数。多变量聚类分析对人口统计学、合并症和地理位置对临终医疗保健利用的影响进行了调整。
2001年死亡的年龄在66岁及以上的78356名医疗保险受益人的全国随机样本。非白人被过度抽样。除终末期肾病项目中的患者外，保留所有在死亡前18个月有完整医疗保险数据的受试者。
临终前6个月的住院天数、费用、院内死亡情况以及两种可预防的住院类型（门诊护理敏感疾病）的发生情况。
样本特征：38%的人没有初级保健就诊；22%的人就诊1 - 2次；19%的人就诊3 - 5次；10%的人就诊6 - 8次；11%的人就诊9次及以上。前一年更多的初级保健就诊次数与临终时更少的住院天数相关（无初级保健就诊的患者为15.3天，就诊9次及以上的患者为13.4天，P < 0.001）、更低的费用（24400美元对23400美元，P < 0.05）、更少的院内死亡（44%对40%，P < 0.01），以及充血性心力衰竭患者（调整后的优势比，aOR = 0.82，P < 0.001）和慢性阻塞性肺疾病患者（aOR = 0.81，P = 0.02）更少的可预防住院情况。
前一年的初级保健就诊与更少且成本更低的临终医院利用相关。增加医疗保险受益人的初级保健可及性可能会降低成本并提高临终时的医疗质量。
